Lulu Mathews¹, M. M. Sunilkumar², Karen Anderson²

School of Public Health, SRMIST Kattankalathur Campus, Chengalpattu

¹Institute of Palliative Medicine, Kozhikode, ²Pallium India, WHO Collaborating Centers (WHOCC) for Training and Policy on Access to Pain Relief, Trivandrum.

Email: iterrymize@gmail.com

ABSTRACT

Background: Assessing the death and dying experience of individuals with palliative care needs is crucial for maintaining quality standards in care delivery. The lack of a culturally relevant tool for the Indian population, the complexities of end-of-life care and the lack of institutional priority for quality assessment and improvement have hindered such assessments. The Institute of Palliative Medicine, Calicut, is a pioneering institute in India, that is delivering palliative care services for the last three decades. However, an objective assessment of the death and dying experience of patients has never been carried out.

Objective: The objective of the study is to increase the assessment of death and dying experience of in-patients from 0% to 50% by June 2019.

Materials and Methods: A3 methodology of quality improvement was used. To explain patient intake, care, discharge, death and bereavement assistance, a process map was created. A fishbone analysis was performed to understand the root causes for not performing the death and dying assessment. The causes were placed on a 2 × 2 grid and key drivers were created. The lack of a culturally suitable instrument was identified as a major barrier. Thus, a tool was developed and implemented.

Results: Weekly assessment targets and outcomes were plotted on a run chart. Assessments improved after the introduction of the instrument and other interventions. Sustainability measures kept the assessment of death and dying experience over 50% on the run chart.

Conclusion: Using the A3 quality improvement technique helped uncover root issues, create key drivers and meet assessment targets. This exercise helped the institute identify service gaps and recommend changes.

Keywords: Assessment, Death and Dying, Quality Improvement

Dr Seema Mishra, Dr Sushma Bhatnagar

All India Institute of Medical Sciences, New Delhi, India. Email: mishra.abhi294@gmail.com

ABSTRACT

Objectives: Palliative surgery for cancer plays an important role in overall management, by reducing the symptom burden of advanced cancers. There is a paucity of literature related to the field of palliative surgery. We present the clinical spectrum, profile of surgical interventions and outcomes of palliative surgical procedures performed at a tertiary cancer centre involving multiple organ systems.

Materials and Methods: A retrospective analysis of a prospectively maintained database in the past 1 year of a tertiary care cancer centre was performed. Patients fulfilling the criteria of palliative surgery were analysed for clinical spectrum, indications for surgery, palliative surgical procedures and postoperative outcomes.

Results: A total of 74 palliative surgeries were performed in the past 1 year. Palliative surgical procedures were performed most for gastro-oesophageal malignancies (n = 35) followed by colorectal cancers (n = 17) and breast cancer (n = 12). Palliative mastectomy was the second most common procedure performed for advanced breast cancer followed by amputations for musculoskeletal cancers. Symptom relief could be achieved in 80–90% of patients and post-operative morbidity was relatively high amongst hepatobiliary cancer patients.

Conclusion: A significant number of cancer patients need palliative surgical intervention, with a high burden of advanced cancers. Results of the current study indicate that gastrointestinal cancer patients constitute a major proportion of patients undergoing palliative surgery. Overall results indicate that excellent palliation can be achieved in the majority of patients with acceptable morbidity and hospital stay.

Keywords: Gastro esophageal malignancy, Palliative Surgery, Postoperative Outcomes

Dr. Nandini Vallath

St. John’s Medical College Hospital, Bangalore, Karnataka, India. Email: parvathyasok@gmail.com

ABSTRACT

Objectives: Pain contributes significantly to serious health-related suffering. Evidence suggests inadequate assessment and management of moderate-to-severe pain in patients reaching healthcare services. This study done at a tertiary care academic centre aims to assess the knowledge, attitudes and practices of specialists when treating patients with severe persistent pain.

Materials and Methods: A cross-sectional online survey using a structured Google Form was conducted amongst clinicians from various specialties, using email and messaging platforms, with responses anonymised, to ensure confidentiality. The questionnaire tool was designed to elicit knowledge, attitude and individual practices when managing pain. The data were then thematically analysed using MS Excel.

Results: Respondents included specialists from medical (63%), surgical (21%) and other fields (16%), with experience ranging from <3 years (36%), 5–10 years (39%), 10–20 years (18%) and >20 years (7%) and 70% were in a position to plan pain treatment. While 70% frequently assessed pain severity, only 46% did so proactively. When managing severe persistent pain independently, 31.6% felt neutral, 31.6% somewhat confident and 30% expressed low confidence. 30% of respondents were uncomfortable managing severe persistent pain. Besides palliative medicine, specialists referred their patients for pain management to speciality clinics (9%) and physical medicine and rehabilitation (19%). When asked about limiting opioid analgesics to end-stage cancer, 75% disagreed. However, 45% had concerns about addiction and respiratory depression. 36.8% strongly agreed with the importance of addressing psychosocial factors and involving multidisciplinary teams, when treating severe persistent pain. Hesitation to prescribe strong opioids was expressed by 43% and 15% voted for additional training in managing severe persistent pain.

Conclusion: The study results suggest a need for collaborative academics on the assessment and management of severe persistent pain including safe and rational use of opioid analgesics. It also suggests policy and process interventions to enable multimodal pain management to alleviate the suffering due to severe persistent pain.

Keywords: Persistent pain management, Severe pain management, Severe persistent pain, Specialist-clinicians

Dr. S. P. Vibha², Dr. Vaishnavi³

Swami Vivekananda Youth Movement ¹Bangalore, ²Mysuru, ³Dharwad. Email: gowthami@svym.org.in

ABSTRACT

Objectives: Managing symptoms such as pain, breathlessness and fatigue poses significant challenges in patients with advanced diseases. This study was conducted to enumerate symptom burden profiles of patients registered in Home-based Palliative Care Programme implemented by SVYM in Mysuru, Bengaluru and Hassan cities and to assess effectiveness of palliative care programme interventions in alleviating the symptoms.

Materials and Methods: 400 participants were interviewed through convenience sampling for the purpose of the study. Edmonton’s symptom assessment scale (ESAS) was used to assess patients during registration and at least 3-week post-intervention. Results are analysed using Chi-squared test and paired t-test for testing for statistical significance.

Results: Amongst 400 patients (mean age 60, 60% female), 80% were from lower socioeconomic backgrounds. At baseline, 95% experienced severe physical distress, 77.5% emotional distress and 72.5% impaired well-being (ESAS). On average, patients spent Rs 7,000 (Rs 2,000–16,000) monthly on palliative care. After prompt treatment, 75% showed significant symptom reduction, 55% had pain relief and 58% improved emotionally. These results were statistically significant (P < 0.05). Programme cost per patient was Rs 2,000/month, reducing patient costs to under Rs 2,500/month after 6 months, a 3-fold reduction.

Conclusion: Collaborative, multidisciplinary care using validated tools enhances effective symptom management in palliative care and reduces financial toxicity for patients and families in need of palliative care.

Keywords: Edmonton’s symptom assessment scale, Holistic care, Home-based palliative care, Palliative care, Symptom burden

Seema R. Rao, Srinagesh Simha, Santosh K. Chaturvedi

Bangalore Hospice Trust- Karunashraya, Bengaluru, Karnataka, India. Email: michelle.normen@karunashraya.org

ABSTRACT

Objectives: Spiritual care is a vital dimension of palliative care but remains a complex concept with diverse interpretations. To explore healthcare providers’ foundational understanding of spirituality in palliative care, 25 participants in 3-day spirituality workshop submitted reflective essays. These reflections provided valuable insights into the participants’ pre-existing beliefs and perceptions, offering a baseline understanding to guide the workshop design.

Materials and Methods: A content analysis of 25 reflective essays to identify recurring themes and patterns in participants’ understanding of spirituality. Using an inductive approach, the reflections were coded and grouped into themes based on the semantic content of the text. This analysis resulted in three overarching themes: (1) The meaning of spirituality in palliative care, (2) the influence of spirituality in palliative care and (3) the process of providing spiritual care.

Results: The theme ‘Meaning of Spirituality’ included participants’ interpretations of spirituality as a deeply personal journey involving search for meaning and purpose and answers to suffering. It included individual meaning-making, religious coping, peace and connectedness, with no finite answers. The theme ‘Influence of Spirituality’ captured how spirituality-shaped experiences and practices of patients and families, serving both as a source of strength and distress. The final theme ‘Process of Spiritual Care’ focussed on how spirituality can be assessed and provided in a palliative care setting, highlighting the need for active listening, person- and family-centred care and accompaniment.

Conclusion: These findings reveal diverse interpretations of spirituality in palliative care, offering valuable insights to inform the design of educational workshops.

Keywords: Content analysis, Healthcare providers, Palliative care, Reflective writing, Spirituality

Dharitri Swain

All India Institute of Medical Sciences Bhubaneswar, Odisha, India. Email: con_asha@aiimsbhubaneswar.edu.in

ABSTRACT

Objectives: Nurses play a vital role in delivering this care, yet many lack sufficient training, leading to variability in care quality. This study examines how palliative care training impacts the self-efficacy of nurses and the satisfaction levels of family caregivers in a tertiary care setting.

Materials and Methods: A quasi-experimental study with one group pre– post-design, involving 100 nursing officers working in critical care units of a tertiary hospital, was adopted. The participants’ self-efficacy and knowledge levels were assessed using valid and reliable structured tools. The structured palliative care training programme spanned 15 modules over 12 weeks through participatory learning followed by assigning the patients to practice the skill. The study was approved by the institute’s ethical committee.

Results: The training led to a statistically significant improvement in nurses’ self-efficacy, with the mean score increasing from 39.1 to 46.57. The knowledge score also rose from a mean of 13.85 to 15.41, indicating a substantial gain in the participants’ understanding of palliative care. Family caregiver satisfaction improved significantly, particularly in communication, emotional support and responsiveness to patients’ needs. There was a notable correlation between the nurses’ increased self-efficacy and the heightened satisfaction levels reported by caregivers.

Conclusion: This study provides strong evidence that structured palliative care training can significantly enhance both the self-efficacy of nurses and their knowledge, leading to improved caregiver satisfaction. Given the increasing demand for palliative care services and the growing burden of chronic and life-limiting conditions, integrating ongoing palliative care training into nursing education is highly recommended.

Keywords: Family caregiver satisfaction, Knowledge improvement, Nurse self-efficacy, Palliative care, Tertiary care, Training impact